How To Use CPT Code 76831

CPT 76831 is a code for saline infusion sonohysterography, a diagnostic procedure used to evaluate the uterine cavity. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 76831 procedures.

1. What is CPT 76831?

CPT 76831 is a medical billing code used for saline infusion sonohysterography (SIS), a diagnostic procedure that involves the infusion of saline into the uterus to better visualize and evaluate the uterine cavity using ultrasound imaging. This procedure is particularly useful for assessing the endometrial lining, fibroids, or tumors, and can be used in conjunction with other diagnostic procedures such as hysterosalpingography.

2. 76831 CPT code description

The official description of CPT code 76831 is: “Saline infusion sonohysterography (SIS), including color flow Doppler, when performed.”

3. Procedure

1. The patient is placed in the lithotomy position after emptying her bladder.
2. A vaginal speculum is inserted into the vagina.
3. The cervix is prepped with Betadine (an antiseptic solution).
4. A sonohysterographic catheter is passed through the cervix and into the uterus.
5. A 20 mL syringe containing sterile normal saline is attached to the catheter.
6. Instillation of the sterile normal saline is begun slowly under direct sonographic visualization after the speculum is removed.
7. The provider or ultrasound technician applies conductive gel over a condom that has been placed over the transducer.
8. The gel helps in the transmission of the sound waves. An ultrasound machine sends high-frequency sound waves through the probe.
9. The provider moves the transducer around inside the vagina, and images of the reproductive organs are displayed on a monitor. Color flow Doppler may be used for enhanced imaging.
10. At the conclusion of the procedure, the catheter and probe are removed, and the saline is allowed to drain from the uterus.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 76831 services include those experiencing postmenopausal bleeding, those with suspected endometrial fibroids or tumors, and those undergoing infertility evaluations. The procedure is not recommended for pregnant patients or those with active pelvic infections.

5. When to use CPT code 76831

CPT code 76831 should be used when a provider performs a saline infusion sonohysterography to evaluate the uterine cavity for abnormalities such as fibroids, tumors, or endometrial lining issues. It is appropriate to bill this code when the procedure is performed for diagnostic purposes and includes the use of color flow Doppler, if applicable.

6. Documentation requirements

To support a claim for CPT 76831, the following information should be documented in the patient’s medical record:

• Indication for the procedure (e.g., postmenopausal bleeding, suspected fibroids or tumors, infertility evaluation)
• Details of the procedure, including the use of color flow Doppler if applicable
• Findings and interpretation of the ultrasound images
• Any complications or adverse reactions experienced by the patient
• Follow-up recommendations or referrals, if necessary

7. Billing guidelines

When billing for CPT code 76831, it is important to follow payer-specific guidelines and rules. If only the physician’s interpretation of the radiology service is being reported, modifier 26 should be appended to the radiology code. If only the technical component is being reported, modifier TC should be appended. However, some payer policies may exempt hospitals from appending modifier TC, as their portion is inherently technical. Do not append a professional or technical modifier when reporting a global service in which one provider renders both components.

8. Historical information

CPT 76831 was added to the Current Procedural Terminology system on January 1, 1998. The code was changed on January 1, 2004, from its previous descriptor, “Hysterosonography, with or without color flow Doppler.”

9. Similar codes to CPT 76831

Five similar codes to CPT 76831 and how they differ are:

1. CPT 58340: This code is used for the introduction of saline for saline infusion sonohysterography, rather than the entire SIS procedure.
2. CPT 76830: This code is for a transvaginal ultrasound examination, which does not involve the infusion of saline into the uterus.
3. CPT 76856: This code is for a pelvic ultrasound examination, which is a more general examination of the pelvic organs and does not involve saline infusion.
4. CPT 76857: This code is for a limited pelvic ultrasound examination, which is a focused examination of specific pelvic structures without saline infusion.
5. CPT 74740: This code is for hysterosalpingography, a radiological imaging procedure that evaluates the endometrial cavity and fallopian tubes using contrast material and fluoroscopy, rather than ultrasound imaging.

10. Examples

Here are 10 detailed examples of CPT code 76831 procedures:

1. A 45-year-old woman with postmenopausal bleeding undergoes a saline infusion sonohysterography to evaluate the endometrial lining for potential abnormalities.
2. A 32-year-old woman with a history of recurrent miscarriages undergoes a saline infusion sonohysterography as part of an infertility evaluation to assess the uterine cavity for possible structural issues.
3. A 50-year-old woman with abnormal uterine bleeding and suspected endometrial polyps undergoes a saline infusion sonohysterography to confirm the presence of polyps and determine their size and location.
4. A 38-year-old woman with pelvic pain and suspected adenomyosis undergoes a saline infusion sonohysterography to evaluate the uterine cavity and endometrial lining for signs of the condition.
5. A 28-year-old woman with a history of irregular menstrual cycles and suspected endometrial hyperplasia undergoes a saline infusion sonohysterography to assess the thickness and appearance of the endometrial lining.
6. A 40-year-old woman with a known uterine fibroid undergoes a saline infusion sonohysterography to monitor the size and location of the fibroid and determine if it is causing any distortion of the uterine cavity.
7. A 35-year-old woman with a history of ectopic pregnancy undergoes a saline infusion sonohysterography as part of a fertility evaluation to assess the uterine cavity for any structural abnormalities that may contribute to future ectopic pregnancies.
8. A 48-year-old woman with a suspected uterine septum undergoes a saline infusion sonohysterography to confirm the presence of the septum and determine its size and extent.
9. A 30-year-old woman with a history of Asherman’s syndrome undergoes a saline infusion sonohysterography to evaluate the uterine cavity for any remaining adhesions or scarring following surgical treatment.
10. A 42-year-old woman with a known endometrial tumor undergoes a saline infusion sonohysterography to monitor the size and location of the tumor and assess its impact on the uterine cavity.